Supported Employment: Getting Started with ... - SAMHSA Store

Getting Started 

with Evidence-Based 

Practices 

Supported 

Employment 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Mental Health Services 

www.samhsa.gov

Getting Started 

with Evidence-Based 

Practices 



U.S. Department of Health and Human Services 


Center for Mental Health Services

Acknowledgments 

This document was produced for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract number 

280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. Department 

of Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served as 

the Government Project Officers. 

Disclaimer 

The views, opinions, and content of this publication are those of the authors and contributors and 

do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services 

(CMHS), SAMHSA, or HHS. 

Public Domain Notice 

All material appearing in this document is in the public domain and may be reproduced or 

copied without permission from SAMHSA. Citation of the source is appreciated. However, 

this publication may not be reproduced or distributed for a fee without the specific, written 

authorization from the Office of Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication 

This publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please call 

SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English 

and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services Administration. Supported Employment: Getting 

Started with Evidence-Based Practices. DHHS Pub. No. SMA-08-4364, Rockville, MD: Center 

for Mental Health Services, Substance Abuse and Mental Health Services Administration, 

U.S. Department of Health and Human Services, 2009. 

Originating Office 



1 Choke Cherry Road 

Rockville, MD 20857 

DHHS Publication No. SMA-08-4364 

Printed 2009

Getting Started with 

Evidence-Based Practices 

Getting Started with Evidence-Based Practices gives you 

an overview of the activities that are generally involved in 

implementing EBPs and tells you how to make EBPs culturally 

competent. This booklet is particularly relevant to the following: 

n Mental health authorities; and 



n Agency staff who develop and manage EBP programs. 

For references, see the booklet The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs created 

by the Center for Mental Health Services, Substance Abuse and 

Mental Health Services Administration, U.S. Department of Health 

and Human Services. 

This booklet is part of the Supported Employment KIT that includes 

a DVD, CD-ROM, and seven booklets: 

How to Use the Evidence-Based Practices KITs 

Getting Started with Evidence-Based Practices 

Building Your Program 

Training Frontline Staff 

Evaluating Your Program 

The Evidence 

Using Multimedia to Introduce Your EBP

What’s in Getting Started with 


Consensus Building: Build Support for Change ........3 

Integrate the EBP into Policies and Procedures ........5 

Assess Training Needs .........................7 



Monitor and Evaluate Regularly ..................9 

Maximize Effectiveness by Making Services 

Culturally Competent .........................11

Getting Started with 


Consensus Building: 

Build Support for Change 

Within a system, change affects 

stakeholders differently. Consequently, 

when making changes in the mental 

health system, mental health agencies 

should expect varied reactions from 

staff, community members, consumers, 

and families. Since misunderstandings 

can stymie your efforts to implement 

EBPs, it is important to build consensus 

to implement EBPs in the community. 

Practitioner training alone is not 

effective. The experience of mental 

health authorities and agencies that have 

successfully implemented evidencebased 

practices (EBPs) reinforces that 

fact. Instead, practitioner training must 

be complemented by a broad range of 

implementation activities, including the 

following: 

n Building support for the EBP; 

n Integrating the EBP into agency 

policies and procedures; 

n Training staff agency-wide on basic EBP 

principles; and 

n Allowing for ongoing monitoring and 

evaluation of the program. 

This overview introduces the general 

range of activities involved in successfully 

implementing EBPs. For guidelines and 

suggestions for EBP‐specific activities, see 

the remaining sections of each KIT. 

Getting Started with EBPs 3

How to build support for your EBP 

Consensus-building activities are designed to build 

support for implementing EBPs. Here are some 

ways to develop them: 

Step 1 Identify key stakeholders or people who 

will be affected by the EBP. Stakeholders 

may include agency personnel at all 

levels, mental health authority staff, and 

consumer and family representatives. 

Depending on the EBP, you may also 

wish to build relationships with other 

community organizations, such as the 

Department of Vocational Rehabilitation, 

homeless shelters, food banks, police, 

hospitals, peer-support programs, and 

consumer and family groups. 

Step 2 Invite one potential EBP champion from 

each stakeholder group to participate in 

an EBP advisory committee. According 

to agencies that have successfully 

implemented EBPs, identifying ongoing 

champions and forming an advisory 

committee are critical activities. While at 

first you may feel that creating an advisory 

committee slows the process, any amount 

of time used to build stakeholder support is 

worth the effort. 

EBPs have little hope for success if the 

community doesn’t recognize that they are 

needed, affordable, worth the effort, and 

congruent with community values and the 

agency’s practice philosophy. Mental health 

authorities and agency administrators must 

convey to key stakeholders a clear vision 

and a commitment to implementing the 

EBP. By forming an advisory committee 

of potential champions from each 

stakeholder group, you will be able to 

broadly disseminate information in the 

community. After training committee 

members in the basic principles of the EBP, 

ask them to hold informational meetings 

or to regularly disseminate information to 

their stakeholder groups. 

Step 3 Ask for advice. Developing the advisory 

committee and educating its members 

in the EBP early in the planning process 

will allow you to ask committee members 

for their advice during all phases of the 

implementation process. Community 

members may help assess how ready 

the community and the agency are to 

implement the EBP and its activities. 

Once the EBP is in place, committee 

members can keep EBP staff informed of 

relevant community trends that may have 

an impact on providing the EBP services. 

EBP advisory committees are crucial 

for sustaining the EBP over time. When 

EBP staff turn over, or other well-trained 

staff leave and must be replaced, or when 

funding streams or program requirements 

change, community and political alliances 

are essential. A well-established committee 

can champion the EBP through changes. 

Step 4 Build an action plan. Once key 

stakeholders basically understand the EBP, 

have your advisory committee develop an 

action plan for implementation. Action 

plans outline activities and strategies 

involved in developing the EBP program, 

including the following: 

nIntegrating the EBP principles into 

mental health authority and agency 

policies and procedures; 

nOutlining initial and ongoing training 

plans for internal and external 

stakeholders; and 

4 Getting Started with EBPs

nDesigning procedures to regularly 

monitor and evaluate the EBP. 

Base the activities in your action plan on 

the needs of the population you serve, your 

community, and your organization. 

Step 5 Involve the advisory committee in 

an ongoing evaluation of the EBP. 

Committee members can help you 

decide which outcomes you should target. 

They can help you integrate continuous 

quality improvements. 

Integrate the EBP into Policies 

and Procedures 

Examine policies and procedures 

Mental health authorities and agencies that have 

successfully implemented EBPs highlight the 

importance of integrating the EBP into policies and 

procedures. For example, you will immediately face 

decisions about staffing the EBP program. Mental 

health authorities can support the implementation 

To start implementing your EBP 

n Pinpoint key stakeholder groups that will be 

affected by implementing the EBP. 

n Identify potential champions from each group 

and invite them to participate in an EBP 

advisory committee. 

n Ask the committee to advise you during 

the process. 

n Build an action plan. 

n Outline responsibilities for committee 

members, such as: 

o Participating in EBP basic training; 

o Providing basic information about the EBP 

to their stakeholder groups; 

o Advising you during all phases of the 

implementation process; and 

o Participating in an ongoing evaluation 

of the EBP. 


process by integrating staffing criteria into 

regulations. Agency administrators should select 

an EBP program leader and practitioners based 

on mental health authority regulations and 

qualifications that the EBP requires. New EBP 

position descriptions should be integrated into 

the agency’s human resource policies. EBPspecific 

suggestions in Building Your Program 

will help mental health authorities and agency 

staff determine the appropriate mix and number 

of staff, define staff roles, and develop a 

supervision structure. 

Agency administrators and mental health 

authorities should also review administrative 

policies and procedures to ensure that they are 

compatible with EBP principles. For example, 

you may need to modify admission and discharge 

assessment, treatment planning, and servicedelivery 

procedures. Make sure policies and 

procedures include information about how to 

identify consumers who are most likely to benefit 

from the EBP and how to integrate inclusion 

and exclusion criteria into referral mechanisms. 

Integrating EBP principles into policies and 

procedures will build the foundation of the 

EBP program and will ensure that the program 

is sustainable. Examine policies and procedures 

early in the process. While most changes will occur 

in the planning stages, regularly monitoring and 

evaluating the program (see discussion below) 

will allow you to periodically assess the need for 

more changes. 

Identify funding issues 

Identifying and addressing financial barriers is 

critical since specific costs are associated with 

starting new EBP programs and sustaining them. 

Identify short- and long-term funding mechanisms 

for EBP services, including federal, state, local 

government, and private foundation funds. You can 

work with your EBP advisory committee to project 

start up costs by identifying the following: 

n Time for meeting with stakeholders that is not 

reimbursed; 

n Time for staff while in training; 

n Staff time for strategic planning; 

n Travel to visit other model EBP programs; and 

n Costs for needed technology (cell phones and 

computers) or other one-time expenses accrued 

during the initial implementation effort. 

You should also identify funding mechanisms for 

ongoing EBP services and to support continuous 

quality improvement efforts, such as ongoing 

training, supervision, technical assistance, fidelity, 

and outcomes monitoring. In addition, you may 

need to revise rules for reimbursement that are 

driven by service definitions and criteria; this may 

require interagency meetings on the federal, state, 

and local levels. 


Get these valuable resources to help implement your EBP 

Numerous materials are available through the U.S. Department of Health and Human Services 

(http://www.hhs.gov) about using Medicaid and Medicare to fund necessary services. If you are 

implementing EBPs, one useful resource is Using Medicaid to Support Working Age Adults with Serious 

Mental Illnesses in the Community: A Handbook, published by the Assistant Secretary of Planning and 

Evaluation, January 2005. 

http://aspe.hhs.gov/daltcp/reports/handbook.pdf 

This handbook gives you an excellent introduction to the Medicaid program, including essential features, 

eligibility, and coverage of mental health services, community services, and waivers. It also provides helpful 

information for states seeking Medicaid funding to implement the following: 

n Family Psychoeducation; 

n Assertive Community Treatment; 

n Illness Management and Recovery; 

n Integrated Treatment for Co-Occurring Disorders; 

n Medication Management; 

n Supported Employment; 

n Supportive Housing; 

n Consumer-Directed Services; and 

n Peer Support. 

Assess Training Needs 

One of the next steps in implementing your 

EBP is to develop a training plan. You may gauge 

the amount of training needed by assessing the 

readiness of your community. If a community 

doesn’t know about the EBP and doesn’t recognize 

the existing need, you may have to conduct a wide 

range of educational activities. If a community 

already understands the EBP and knows how it may 

address problems that community members want 

to solve, you may need fewer educational activities. 

You can help train key stakeholder groups if 

you first train members of your EBP advisory 

committee and then ask them to disseminate 

information about the purpose and benefits 

of the EBP. 

In addition to assessing training needs in the 

community, agency administrators should gauge 

how well staff across the agency understand the 

EBP. Agency administrators who have successfully 

implemented EBPs highlight the importance of 

providing basic training on the EBP to all levels 

of staff throughout the agency. Educating and 

engaging staff will ensure support for the EBP. 

In the long run, if they are well trained, EBP 

staff will have an easier time obtaining referrals, 

collaborating with staff from other service 

programs, and facilitating a continuum of care. 

Ongoing in-service training is an efficient way to 

provide background information, the EBP practice 

philosophy and values, and the basic rationale 

for EBP service components in a comfortable 

environment. Consider including members of 

your advisory committee in decisions about the 

frequency and content of basic EBP training. 


Offer more intensive training to program 

leaders and practitioners 

While staff at all levels in the agency should 

receive basic EBP training, the program leader and 

practitioners will require more intensive training. 

To help practitioners integrate EBP principles 

into their daily practice, offer comprehensive 

skills training to those who provide EBP services. 

Each KIT contains a variety of EBP-specific 

training tools to help you provide both basic and 

intensive training. 

Although most skills that practitioners need may 

be introduced through these training tools, research 

and experience show that the most effective way to 

teach EBP skills is through on-the-job consultation. 

Consultants may provide comprehensive training 

and case consultation to EBP practitioners. 

Consultants may also help mental health authorities 

and agency administrators to do the following: 

n Provide basic information to key stakeholders; 

n Assess the community’s readiness for change; 

n Assist in integrating EBP principles into policies 

and procedures; and 

Many agencies have also found it useful for 

program leaders and practitioners to become 

familiar with the structure and processes of the 

practice by visiting agencies that have successfully 

implemented the EBP. 

Early in the process, mental health authorities 

and agency administrators must decide how to 

accomplish the following: 

n Identify internal and external stakeholders who 

will receive basic training; 

n Determine how often basic training will be 

offered; 

n Identify who will provide the training; 

n Identify EBP staff and advisory group members 

who will receive comprehensive skills training; 

n Determine the training format for ongoing 

training to EBP staff; and 

n Determine whether EBP staff may visit a model 

EBP program. 

EBP-specific suggestions in Building Your Program 

will help mental health authorities and agency staff 

develop an EBP training plan. 

n Design ongoing training plans. 

In many mental health agencies, turnover of 

staff is high. This means that the EBP will not 

be sustained unless ongoing training is offered to 

all employees. 


Monitor and Evaluate Regularly 

Key stakeholders who implement EBPs may find 

themselves asking two questions: 

n Has the EBP been implemented as planned? 

n Has the EBP resulted in the expected 

outcomes? 

Asking these two questions and using the answers 

to improve your program is a critical component 

for ensuring the success of your EBP. 

n To answer the first question, collect process 

measures (by using the EBP Fidelity Scale and 

General Organizational Index). Process measures 

capture how services are provided. 

n To answer the second question, collect outcome 

measures. Outcome measures capture the results 

or achievements of your program. 

As you prepare to implement an EBP, we strongly 

recommend that you develop a quality assurance 

system using both process and outcome measures 

to monitor and improve the program’s quality from 

the startup phase and continuing through the life 

of the program. Evaluating Your Program in the 

KIT contains an EBP-specific Fidelity Scale, the 

General Organizational Index, and sample outcome 

measures. These measures may be integrated 

into existing quality assurance programs or help 

agencies develop new ones. 

Why you should collect process measures 

Process measures, such as the EBP Fidelity Scale 

and General Organizational Index, help you assess 

whether the core elements of the EBP were put 

into place in your agency. Research tells us that 

the higher an agency scores on a fidelity scale, the 

greater the likelihood that the agency will achieve 

favorable outcomes (Becker et al., 2001; Bond & 

Salyers, 2004). For this reason, it is important to 

monitor both fidelity and outcomes. 

Process measures give agency staff an objective, 

structured way to determine if you are delivering 

services in the way that research has shown will 

result in desired outcomes. Collecting process 

measures is an excellent method to diagnose 

program weaknesses, while helping to clarify 

program strengths. Process measures also give 

mental health authorities a comparative framework 

to evaluate the quality of EBPs across the state. 

They allow mental health authorities to identify 

statewide trends and exceptions to those trends. 

Why you should collect outcome measures 

While process measures capture how services 

are provided, outcome measures capture the 

program’s results. Every service intervention has 

both immediate and long-term consumer goals. 

In addition, consumers have goals for themselves, 

which they hope to attain by receiving mental 

health services. These goals translate into outcomes 

and the outcomes translate into specific measures. 


Some outcomes directly result from an 

intervention, such as getting a job by participating 

in a supported employment program. Others are 

indirect, such as improving consumers’ quality of 

life as a result of having a job. Some outcomes are 

concrete and observable, such as the number of 

days worked in a month. Others are subjective, 

such as being satisfied with EBP services. 

Therefore, you should collect outcome 

measures, such as homelessness, hospitalization, 

incarceration, and recovery, that show the effect 

that services have had on consumers, in addition 

to the EBP fidelity measures. Monitoring fidelity 

and outcomes on an ongoing basis is a good 

way to ensure that your EBP is effective. 

Developing a quality assurance 

system will help you 

n Diagnose your program’s strengths 

and weaknesses; 

n Formulate action plans to improve the 

program; 

n Help consumers achieve their goals for 

recovery; and 

n Deliver mental health services both 

efficiently and effectively. 

How process and outcome data improve EBPs 

Collecting and using process and outcome 

data can improve consumer participation and 

staff performance. 

Consider the following story: 

Participants in a partial hospitalization program 

sponsored by a community mental health center 

consistently showed very little vocational interest or 

activity. Program staff began gathering data monthly 

about consumers’ vocational status and reporting the 

data to their program consultant. Every 3 months, the 

consultant returned the data to them using a simple 

bar graph. 

The positive result of gathering and using information 

about consumers’ vocational activity was evident 

almost immediately. Three months after starting this 

monitoring system, the percentage of the program’s 

consumers who showed an interest or activity in 

vocational areas increased from 36% to 66%. Three 

months later, 72% of program participants were 

involved in some form of vocational activity. 

This example shows that sharing process and 

outcomes data with consumers can stimulate 

participation in your EBP program. 

Similarly, disseminating assessment data can 

enhance the performance of EBP staff and increase 

motivation, professional learning, and a sense 

of accomplishment. In their study of successful 

companies, Peters and Waterman (1982) observed: 

We are struck by the importance of available 

information as the basis for peer comparison. 

Surprisingly, this is the basic control mechanism 

in the excellent companies. It is not the military 

model at all. It is not a chain of command wherein 

nothing happens until the boss tells somebody to 

do something. General objectives and values are set 

forward and information is shared so widely that 

people know quickly whether or not the job is getting 

done — and who’s doing it well or poorly (p. 266). 

Information in Evaluating Your Program will teach 

quality assurance team members how to collect, 

analyze, and use process and outcomes data to 

improve their EBP program. 


Maximize Effectiveness 

by Making Services 

Culturally Competent 

Cultural competence is an approach to delivering 

services that assumes that services are more 

effective when they are provided within the most 

relevant and meaningful cultural, gender-sensitive, 

and age-appropriate context for the people 

being served. 

You can improve the quality of your EBP program 

by ensuring that it is culturally competent — that 

it adapts to meet the needs of consumers from 

diverse cultures. First, it’s important to understand 

what culture and cultural competence are and how 

they affect care. 

What culture is and how it affects care 

Broadly defined, culture is a common heritage or 

set of beliefs, norms, and values that a group of 

people shares. People who are placed — either by 

census categories or by identifying themselves — 

into the same racial or ethnic group are often 

assumed to share the same culture; however, not all 

members who are grouped together will share the 

same culture. 

A great diversity exists within each broad category. 

Some individuals may identify with a given racial 

or ethnic culture to varying degrees, while others 

may identify with multiple cultures, including those 

associated with their religion, profession, sexual 

orientation, region, or disability status. 

Culture is dynamic. It changes continually and 

is influenced both by people’s beliefs and by the 

demands of their environment. Immigrants from 

different parts of the world arrive in the United 

States with their own culture but gradually begin 

to adapt and develop new, hybrid cultures that 

allow them to function in the dominant culture. 

This process is called acculturation. Even groups 

that have been in the U.S. for many generations 

may share beliefs and practices that maintain 

influences from multiple cultures. This complexity 

necessitates an individualized approach to 

understanding culture and cultural identity in 

the context of mental health services. 

Culture influences many aspects of care, 

starting with whether people think care is 

even needed. Culture influences the concerns 

that people bring to the clinical setting, the 

language they use to express those concerns, 

and the coping styles they adopt. 

Culture affects family structure, living 

arrangements, and the degree of support that 

people receive in time of difficulties. Culture 

also influences patterns of help-seeking, whether 

people start with a primary care doctor, a mental 

health program, or a minister, spiritual advisor, or 

community elder. Finally, culture affects whether 

people attach a stigma to mental health problems 

and how much trust they place in the hands 

of providers. 

Culture isn’t just a consumer issue 

It’s easy to think that culture belongs only to 

consumers without realizing how it also applies to 

providers and administrators. Their professional 

culture influences how they organize and deliver 

care. Some cultural influences are more obvious 

than others — such as the manner in which 

practitioners ask questions or how they interact 

with consumers. Less obvious but equally 

important are issues such as the following: 

n The operating hours of an agency; 

n The importance that staff attaches to reaching out 

to family members and community leaders; and 

n The respect that staff gives to the culture of 

consumers who enter their doors. 

Knowing how culture influences so many aspects 

of mental health care underscores the importance 

of adapting agency practices to respond to, 

and be respectful of, the diversity of the 

surrounding community. 


The need for cultural competence 

For decades, many mental health agencies 

neglected to recognize the growing diversity 

around them. Often, people from non-majority 

cultures found programs off-putting and hard to 

access. They avoided getting care, stopped looking 

for care, or — if they managed to find care — they 

dropped out. 

Troubling disparities resulted. Many minority 

groups faced lower access to care, lower use of care, 

and poorer quality of care. Disparities were most 

apparent for racial and ethnic minority groups, 

such as the following: 

n African Americans; 

n American Indians and Alaska Natives; 

n Asian Americans; 

n Hispanic Americans; and 

n Native Hawaiians and other Pacific Islanders. 

But disparities also affect many other groups, 

such as the following: 

n Women and men; 

n Children and older adults; 

n People from rural areas; 

n People of different religions; 

n People with different sexual orientations; and 

n People with physical or developmental 

disabilities. 

Altogether, those disparities meant that millions 

of people suffered needless disability from 

mental illnesses. 

Starting in the late 1980s, the mental health 

profession responded to the issue of disparity with 

a new approach to care called cultural competence. 

Originally cultural competence was defined as a 

set of congruent behaviors, attitudes, and policies 

that come together in a system, agency, or among 

professionals to enable people to work effectively 

in cross-cultural situations. Cultural competence is 

intended to do the following: 

n Improve consumers’ access to care; 

n Build trust; and 

n Promote consumers’ engagement and retention 

in care. 

What is cultural competence? 

In the Surgeon General’s report on the topic 

cultural competence, it is defined in the most 

general terms as 

“… the delivery of services responsive to the cultural 

concerns of racial and ethnic minority groups, 

including their languages, histories, traditions, 

beliefs, and values” (U.S. Department of Health 

and Human Services, 2001). 

In most cases, cultural competence refers to sets of 

guiding principles developed to increase the ability 

of mental health providers, agencies, or systems to 

meet the needs of diverse communities, including 

racial and ethnic minorities. 

While consumers, families, providers, policymakers, 

and administrators have long acknowledged the 

intrinsic value of cultural competence, insufficient 

research has been dedicated to identifying its key 

ingredients. Therefore, the field still struggles to 

define cultural competence, put it into operation, 

and measure it. 

The word competence is somewhat misleading. 

It usually implies a set of criteria on which to 

evaluate a program. But this is not yet true; 

cultural competence is still underresearched. 

In this context, competence means that the 

responsibility to tailor care to different cultural 

groups belongs to the system, not to the consumer. 

Every provider or administrator who is involved 

in delivering care — from mental health 

authorities down to clinical supervisors and 

practitioners — bears responsibility for trying to 

make programs accessible, appropriate, appealing, 

and effective for the diverse communities 

that they serve. Many do it naturally. 


How cultural competence 

relates to EBPs 

According to the Surgeon General, evidence-based 

practices are intended for every consumer who 

enters care, regardless of his or her culture. But 

programs often need to adjust EBPs to make them 

accessible and effective for cultural groups that 

differ in language or behavior from the original 

study populations. The adjustments should help, 

rather than interfere with, a program’s ability to 

implement EBPs using the KITs. 

In a nutshell, to deliver culturally competent 

EBPs, you must tailor to the unique communities 

you serve either the practice itself or the context 

in which the practice is delivered. In time, specific 

fidelity measures may be available to assess a 

program’s cultural competence, but not yet. The 

evidence base of cultural competence is too small. 

While the evidence is being collected, programs 

can and should tailor EBPs to each cultural 

group they serve, for instance, by translating 

their informational brochures into the languages 

often used in their communities. For more 

suggestions, see How to put cultural competence 

into practice. 

Many providers ask, 

How can we know if EBPs apply to a particular 

ethnic, racial, or cultural group if the research 

supporting those practices was done on a very 

different population? 

The answer is that we will not know for sure 

until we try; but the limited research that 

does exist suggests that EBPs, perhaps with 

minor modifications, work well across cultures. 

Furthermore, because EBPs represent the highest 

quality of care currently available, it is a matter of 

fairness and prudence to provide them to all people 

who may need them. Yet the question remains, 

How can we do this effectively? 

How to put cultural competence 

into practice 

Since the goal is for all programs to be more 

culturally competent, we offer a variety of 

straightforward steps to help agency administrators 

respond more effectively to the people they serve. 

These steps apply to all facets of a program; they 

are not restricted to the EBP program alone. Please 

note that the following guidelines are meant to be 

illustrative, not prescriptive: 

n Understand the racial, ethnic, and cultural 

demographics of the population served. 

n Become most familiar with one or two of the 

groups you most commonly encounter. 

n Create a cultural competence advisory committee 

consisting of consumers, family, and community 

organizations. 

n Translate your forms and brochures. 

n Offer to match a consumer with a practitioner 

who has a similar background. 

n Have ready access to qualified interpreters. 

n Ask consumers about their cultural backgrounds 

and identities. 

n Incorporate cultural awareness into consumers’ 

assessment and treatment. 

n Tap into natural networks of support, such as 

the extended family and community groups that 

represent the consumer’s culture. 

n Reach out to religious and spiritual organizations 

to encourage referrals or as another network 

of support. 

n Offer training to staff in culturally responsive 

communication or interviewing skills. 

n Understand that some behaviors that one culture 

may consider to be signs of psychopathology are 

acceptable in a different culture. 

n Be aware that consumers from other cultures 

may hold different beliefs about causes and 

treatment of illness. 


How mental health authorities 

can help 

We offer you a few examples of how public 

mental health authorities can help develop a more 

culturally competent mental health system: 

n Designate someone with part-time or full-time 

responsibility for improving and monitoring 

cultural competence. 

n Create a strategic plan to incorporate cultural 

competence into the mental health system. 

n Establish an advisory committee that includes 

representatives from all the major racial, ethnic, 

and cultural groups you serve. 

n Address barriers to care (including cultural, 

linguistic, geographic, or economic barriers). 

n Promote staffing that reflects the composition of 

the community you serve. 

n Promote regular organizational self-assessments 

of cultural competence. 

n Collect and analyze data to examine disparities in 

services. 

n Designate specific resources for cultural 

competence training. 

n Include cultural competence in quality-assurance 

and quality-improvement activities. 

For more suggestions about adapting EBPs to 

diverse groups, see the remaining booklets in 

the KIT. 

A look at cultural competence 

through five vignettes 

Vignette — Integrated Treatment for 

Co‐Occurring Disorders 

Kevin is a 40-year-old African American homeless 

man in Chicago who, for a decade, cycled between 

jail, street, and shelter. At the shelter, he refused 

help for what the staff believed was a longstanding 

combination of untreated schizophrenia and 

alcoholism. 

He became so drunk one night that he walked in 

front of a car and was seriously injured. While in the 

hospital, he was treated for his injuries, as well as 

placed on anti-psychotic medications after psychiatrists 

diagnosed him with schizophrenia. 

When he was discharged from the hospital, Kevin 

was referred to an integrated treatment program 

for co-occurring disorders. Realizing that Kevin 

needed aggressive treatment to avoid spiraling into 

homelessness again, the head of the treatment team 

recommended concurrently treating the alcoholism 

and schizophrenia. The integrated treatment 

specialist was an African American psychiatrist who 

appreciated the years of alienation, discrimination, 

and victimization that Kevin described as having 

contributed to his co-occurring disorders. 

The integrated treatment specialist worked hard to 

develop a trusting relationship. He worked with the 

treatment team to ensure that, in addition to mental 

health and substance abuse treatment, Kevin received 

social skills training and a safe place to live. When 

Kevin was well enough, and while he continued 

receiving group counseling for his co-occurring 

disorders, one of his first steps toward recovery was to 

reconnect with his elderly mother who had not heard 

from him in 10 years. 


Vignette — Assertive Community Treatment 

A minister in Baltimore contacted the city’s Assertive 

Community Treatment (ACT) program with an unusual 

concern: one of his congregants disclosed to him 

that another member of the congregation — an 

older woman from Jamaica — was beating her adult 

daughter for “acting crazy all the time.” The Jamaican 

mother might even be locking her adult daughter in 

the basement, according to the congregant. 

One year before, an ACT team member had reached 

out to local ministers to tell them about the program. 

The ACT team had realized that better communication 

and referrals were needed. Stronger connections 

across organizations would improve chances for 

recovery by enhancing social support and adherence 

to treatment. Some consumers, however, believed that 

treatment was against their religion. 

The ACT team member obtained a court order to 

allow authorities to enter the Jamaican mother’s 

home. They discovered the traumatized 25-year-old 

daughter locked in the basement, actively psychotic, 

and bearing marks of physical abuse. The team 

diagnosed the daughter with schizophrenia and 

arranged suitable housing for her. 

The team arranged for an intense combination 

of medications and individual and group therapy, 

including trauma care and social skills training. 

Through links to the church and the community, 

the team helped the daughter get clothing and 

spiritual support. 

The team discovered that the mother’s ethnic 

group from Jamaica believed that her daughter’s 

mental illness was a sign of possession by the devil. 

The team reached out to the mother to educate her 

about schizophrenia and to set the stage for the 

daughter’s eventual return to her mother’s household. 

Vignette — Illness Management and Recovery 

Lupita, a 17-year-old high school senior, arrived in 

an emergency room after a suicide attempt. The 

psychiatrist on call happened to be the same one who 

had diagnosed Lupita’s bipolar disorder a year before. 

He thought that she had been taking her medications 

properly, but blood tests now revealed no trace of 

psychiatric medication. 

The psychiatrist tried to communicate with Lupita’s 

anxious parents who were waiting in the visitor 

area, only to learn that they spoke only Spanish, 

not English. The psychiatrist had mistakenly assumed 

that because Lupita, a second-generation Mexican 

American, was highly acculturated, so were her 

parents. She contacted the hospital’s bilingual Illness 

Management and Recovery (IMR) practitioner who 

learned that the parents felt powerless for months 

as they watched their daughter sink into a severe 

depression, as she was not taking her medications. 

The IMR practitioner, whose family had similarly 

emigrated from a rural region of Mexico, knew 

to gently ask the parents if they could read and 

understand the dosage directions for Lupita’s 

medication. Finding that the parents had limited 

literacy in both English and Spanish, they tailored the 

treatment program so that it would not depend on 

the written word. They also introduced Lupita and 

her family to the IMR program. The hospital had 

organized programs for Spanish-speaking families 

because of the large number of Latinos in the area. 

During the weekly sessions, the IMR practitioner 

translated for the family and helped them schedule 

Lupita’s psychiatric visits. Together they apportioned 

the correct combination of pills in a daily pill 

container. Understanding that the family had no 

phone, the IMR practitioner worked with them to find 

a close neighbor who might allow them to use the 

phone to relay messages from her and to contact her 

if Lupita stopped taking her medications. 


Vignette — Family Psychoeducation 

In times of difficulties, many Native Hawaiians rely on 

their elders, traditional healers, families, or teachers 

to provide them with wisdom and cultural practices to 

resolve problems. One such practice is hoòponopono, 

which is a traditional cultural process for maintaining 

harmonious relationships among families through 

a structured discussion of conflicts. Hoòponopono 

is also used by people for personal healing and 

guidance in troubled times. 

When Kawelo lost his job as an electrician, his mental 

health practitioner asked him if he had a family elder 

who knew of community elders who were familiar 

with traditional Hawaiian healing practices. Kawelo’s 

practitioner recognized the importance of tapping into 

this community support and suggested that his family 

seek out hoòponopono. 

Kawelo and his practitioner contacted the family and 

elders to arrange a meeting. At the meeting, the 

practitioner provided information about Kawelo’s 

illness. They discussed symptoms and warning signs 

of relapse. 

The therapist asked the elders how the group could 

support Kawelo’s recovery. After lengthy deliberations, 

the family decided that one way to help Kawelo was to 

participate in ho’oponopono to understand the types 

of problems that he was experiencing and identify 

how the family could help him heal himself. Some 

members of the family also agreed to participate in 

a Family Psychoeducation (FPE) program to learn 

more about his mental illness and ways to support 

his recovery. 

Vignette — Supported Employment 

Jing is a bilingual employment specialist. By 

informally surveying her caseload, she estimates 

that about 30% of the consumers with whom she 

works are Asian, but they come from vastly different 

backgrounds, ranging from Taiwan to Cambodia, with 

different educational levels. 

One of the consumers with bipolar disorder with 

whom she works recently immigrated from China. He 

has a high school education, but speaks Mandarin and 

very little English. Fluent in Mandarin, Jing is able to 

conduct a careful assessment of the consumer’s job 

skills and a rapid, individualized job search. 

Jing identifies several import-export businesses in 

the area that have monolingual Mandarin-speaking 

employees. She and the consumer secure a position, 

but it pays less than one the consumer would qualify 

for if he spoke English. Jing and the consumer 

decide to take the position while, at the same time, 

participating in a quick-immersion night program in 

English as a Second Language. 

Jing provides follow-along job support during the next 

few months. When the consumer’s English is better, 

Jing and the consumer search for and find a higher 

paying job. Jing continues follow-along services to 

support the consumer in his adjustment to the greater 

demands of the new position. 

Through the FPE program, the family participated in 

structured multi-family group sessions. Because an 

important level of healing in Native Hawaiian culture 

involves sharing positive and negative emotions in an 

open, safe, and controlled environment, the family’s 

participation in a combination of ho’oponopono 

and FPE was successful in helping Kawelo. 


Selected resources on cultural competence 

The following resources on cultural competences 

apply to all EBPs. These resources are for 

consumers and families, mental health authorities, 

administrators, program leaders, and practitioners. 

For resources related to each EBP, see The 

Evidence in each KIT. 

National resources for consumers 

and families 


Substance Abuse and Mental Health Services 

Administration 

SAMHSA’s Health Information Network 


Phone: (877) SAMHSA-7 (1-877-726-4727) 

(English and Español) 

www.samhsa.gov/shin 

First Nations Behavioral Health Confederacy 

Phone: (406) 732-4240 Montana 

Phone: (505) 275-3801 Albuquerque, NM 

pauletterunningwolf@hotmail.com 

National Alliance on Mental Illness (NAMI) 

Colonial Place Three 

2107 Wilson Boulevard, Suite 300 

Arlington, VA 22201-3042 

Phone: (800) 950-NAMI (6264) 

Fax: (703) 524-9094 

TTY: (703) 516-7227 

www.nami.org 

National Institute of Mental Health (NIMH) 

Office of Communications 

6001 Executive Boulevard 

Room 8184, MSC 9663 

Bethesda, MD 20892-9663 

Phone: (866) 615-NIMH (6464) 

Fax: (301) 443-4279 

TTY: (301) 443-8431 

www.nimh.nih.gov 

National Latino Behavioral Health Association 

P.O. Box 387 

506 Welch, Unit B 

Berthoud, CO 80513 

Phone: (970) 532-7210 

Fax: (970) 532-7209 

www.nlbha.org 

National Leadership Council on African American 

Behavioral Health 

6904 Tulane Drive 

Austin, TX 78723-2823 

Phone: (512) 929-0142 

Fax: (512) 471-9600 

tkjohnson@mail.utexas.edu 

Mental Health America 

2001 North Beauregard Street, 6th Floor 

Alexandria, VA 22311 

Phone: (800) 969-6642 

Phone: (703) 684-7722 

Fax: (703) 684-5968 

TDD: (800) 433-5959 

www.nmha.org 

National Asian American Pacific Islander 

Mental Health Association 

1215 19th Street, Suite A 

Denver, CO 80202 

Phone: (303) 298-7910 

Fax: (303) 298-8081 

www.naapimha.org 

Resources for mental health authorities 

Aponte, C., & Mason, J. (1996). A demonstration 

project of cultural competence self-assessment 

of 26 agencies. In M. Roizner, A practical 

guide for the assessment of cultural competence 

in children’s mental health organizations 

(pp. 72–73). Boston: Judge Baker 

Children’s Center. 


California Mental Health Ethnic Services 

Managers with the Managed Care Committee. 

(1995). Cultural competency goals, strategies 

and standards for minority health care to 

ethnic clients. Sacramento: CA: Mental Health 

Directors’ Association. 

Carpinello, S. E., Rosenberg, L., Stone, J., 

Schwager, M., and Felton, C. J. (2002). Best 

practices: New York State’s campaign to 

implement evidence-based practices for people 

with serious mental disorders. Psychiatric 

Services, 53(2), 153–5. 

Chorpita, B. F., & Nakamura, B. J. (2004). Four 

considerations for dissemination of intervention 

innovations. Clinical Psychology: Science and 

Practice, 11, 364–367. 

Dillenberg, J., & Carbone, C. P. (1995). Cultural 

competency in the administration and delivery of 

behavioral health services. Phoenix, AZ: Arizona 

Department of Health Services. 

Knisley, M. B. (1990). Culturally sensitive language: 

community certification standards. Columbus, 

OH: Ohio Department of Mental Health. 

National Implementation Research Network. 

(2003). Consensus statement on evidence-based 

programs and cultural competence. Tampa, FL: 

Louis de la Parte Florida Mental Health Institute. 

New York State Office of Mental Health. (1998). 

Cultural competence performance measures for 

managed behavioral healthcare programs. Albany, 

NY: New York State Office of Mental Health. 

New York State Office of Mental Health. 

(1998). Final Report: Cultural and Linguistic 

Competency Standards. Albany, NY: New York 

State Office of Mental Health. 

Pettigrew, G. M. (1997). Plan for culturally 

competent specialty mental health services. 

Sacramento, CA: California Mental Health 

Planning Council. 

Phillips, D., Leff, H. S., Kaniasty, E., Carter, 

M., Paret, M., Conley, T., & Sharma, M. 

(1999). Culture, race and ethnicity (C/R/E) 

in performance measurement: A compendium 

of resources; Version 1. Cambridge, MA: The 

Human Services Research Institute (Evaluation 

Center@HSRI). 

Siegel, C., Davis-Chambers, E., Haugland, G., 

Bank, R., Aponte, C., & McCombs, H. (2000). 

Performance measures of cultural competency in 

mental health organizations. Administration and 

Policy in Mental Health, 28, 91–106. 

U.S. Department of Health and Human Services. 

(1996). Consumer mental health report card. 

Final report: task force on a consumer-oriented 

mental health report card. Rockville, MD: 


Administration. 


(2000). Cultural competence standards in 

managed mental health care services: Four 

underserved/underrepresented racial/ethnic 

groups. HHS Pub. No. SMA 00-3457. Rockville, 

MD: Center for Mental Health Services, 


Administration. 


(1999). Mental health: A report of the Surgeon 

General. Rockville, MD: U.S. Department of 

Health and Human Services, Substance Abuse 

and Mental Services Administration, Center for 

Mental Health Services, National Institutes of 

Health, National Institute of Mental Health. 

Western Interstate Commission for Higher 

Education (WICHE) and Human Services 

Research Institute (The Evaluation Center@ 

HSRI). (1999). Notes from a roundtable 

on conceptualizing and measuring cultural 

competence. Boulder, CO: WICHE, Publications. 


Western Interstate Commission for Higher 

Education (WICHE). (1997). Cultural 

competence standards in managed mental health 

care for four underserved/ under represented 

racial/ethnic groups. Boulder, CO: WICHE 

Publications. 









Hogg Foundation for Mental Health 

The University of Texas at Austin 

P.O. Box 7998 

Austin, TX 78713-7998 

Phone: (800) 404-4336 

Fax: (512) 471-5041 

http://www.hogg.utexas.edu 

Resources for mental health administrators 

Lopez, L., Jackson, V. H. (1999). Cultural 

competency in managed behavioral healthcare: 

An overview. In V. H. Jackson, L. Lopez 

(Eds.). Cultural competency in managed 

behavioral healthcare. Providence, RI: Manisses 

Communications Group, Inc. 









Human Services Research Institute 

2336 Massachusetts Avenue 

Cambridge, MA 02140 

Phone: (617) 876-0426 

www.hsri.org 

National Alliance of Multi-Ethnic Behavioral 

Health Associations 

1875 I Street, NW 

Suite 5009 

Washington, DC 20006 

Phone: (202) 429-5520 

www.nambha.org 

National Center for Cultural Competence 

Georgetown University Center for Child and 

Human Development 

3300 Whitehaven Street, NW 

Suite 3300 

Washington, DC 20057 

Phone: (202) 687-5387 

TTY: (202) 687-5503 

Western Interstate Commission for 

Higher Education (WICHE) 

Mental Health Program 

P.O. Box 9752 

Boulder, CO 80301-9752 

www.wiche.edu 

Resources for program leaders 

Barrio, C. (2000). The cultural relevance of 

community support programs. Psychiatric 

Services, 51, 879–874. 

Issacs, M. R., & Benjamin, M. P. (1991). Toward 

a culturally competent system of care: programs 

which utilize culturally competent principles. 

Washington, DC: Georgetown University Child 

Development Center. 


Leong, F. (1998). Delivering and evaluating mental 

health services for Asian Americans. In Report of 

the roundtable on multicultural issues in mental 

health services evaluation. Tucson, AZ: Human 

Services Research Institute (The Evaluation 

Center,@HSRI). 

Musser-Granski, J., & Carrillo, D. F. (1997). The 

use of bilingual, bicultural paraprofessionals in 

mental health services: issues for hiring, training, 

and supervision. Community Mental Health 

Journal 33, 51–60. 

Phillips, D., Leff, H. S., Kaniasty, E., Carter, 

M., Paret, M., Conley, T., & Sharma, M. 

(1999). Culture, race and ethnicity (C/R/E) in 

performance measurement: A compendium 

of resources; Version 1. Cambridge, MA: Human 

Services Research Institute (The Evaluation 

Center@HSRI). 

Ponterotto, J. G., & Alexander, C. M. (1996). 

Assessing the multicultural competence of 

counselors and clinicians. In L. A. Suzuki, 

P. J. Meller, J. G. Ponterotto (Eds.) Handbook of 

multicultural assessment: clinical, psychological, 

and educational applications (pp. 651–672). San 

Francisco: Jossey-Bass. 

Tirado, M. D. (1996). Tools for monitoring cultural 

competence in health care. San Francisco: Latino 

Coalition for a Healthy California. 


(1999). Mental health: A Report of the Surgeon 

General. Rockville, MD: U.S. Department of 

Health and Human Services, Substance Abuse 

and Mental Health Services Administration, 

Center for Mental Health Services, National 

Institutes of Health, National Institute of 

Mental Health. 


(2001). Mental health: Culture, race, and 

ethnicity. A supplement to mental health: A 

report of the Surgeon General. Rockville, MD: 

U.S. Department of Health and Human Services, 


Administration, Center for Mental Health 

Services. 

Instruments to assess cultural competence 

Consolidated Culturalogical Assessment 

Toolkit (C-CAT) 

Ohio Department of Mental Health, 2003. 

n Measures cultural competence in mental health 

systems and organizations 

n Includes comprehensive training and 

promotional materials 

For more information: 

http://www.ccattoolkit.org/C-CAT.shtml 

Multiethnic Advocates for Cultural Competence 

Columbus, OH 43215 

Phone: (614) 221-7841 

www.maccinc.net 

Cross-Cultural Counseling Inventory (CCCI) 

n Measures knowledge, attitudes, and beliefs 

about cultural diversity 

n Measures cross-cultural counseling skills 


LaFromboise, T., Coleman, H., Hernandez, A. 

(1991). Development and factor structure of 

the cross-cultural counseling inventory-revised. 

Professional Psychology, Research and Practice 

22 (5), 380–388. 


Cultural Acceptability of Treatment Survey (CATS) 

Human Services Research Institute (HSRI), 1998. 

n Measures the cultural competency of services 

n Measures organizational accommodations 

and practices 

n Measures consumer preferences and satisfaction 


Human Services Research Institute 

2336 Massachusetts Avenue 

Cambridge, MA 02140 

Phone: (617) 876-0426 

Fax: (617) 492-7401 

www.hsri.org 

Cultural Competency Assessment Scale (CCAS) 

Nathan S. Kline Institute for Psychiatric 

Research, 2000. 

n Assesses organization’s level of cultural 

competence 

n Consistent with EBP fidelity instruments 


Nathan S. Kline Institute for Psychiatric Research 

140 Old Orangeburg Road 

Orangeburg, NY 10962 

Phone: (845) 398-5500 

Fax: (845) 398-5510 

http://www.rfmh.org/nki/ 

Multicultural Counseling Awareness Scale (MCAS) 

n Assesses cultural awareness, knowledge, 

and skills 

n Self-report of 45 items 


Ponterotto, J. G., Alexander, C. M. (1996) 

Assessing the multicultural competence of 

counselors and clinicians in L. A. Suzuki, 

P. J. Meller, J. G. Ponterotto (Eds.) Handbook of 

multicultural assessment: Clinical, psychological, 

and educational applications (pp. 651–672) San 

Francisco: Jossey-Bass. 

Multicultural Counseling Inventory (MCI) 

n Assesses awareness, knowledge, skills, 

and relations 

n Self-report of 43 items 


Sodowsky, G. R., Taffe, R. C., Gutkin, T. B., 

Wise, S. L. (1994). Development of the 

multicultural counseling inventory: a selfreport 

measure of multicultural competencies. 

Journal of Counseling Psychology 41, 137–148. 

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DHHS Publication No. SMA-08-4364 

Printed 2009 

22576.0409.7765020404

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